Going Around Your Ass to Get to Your Elbow

The elbow, a hinge joint, has a lot of similar functional roles as the knee. As I touched on in a recent article, despite the perceived simplicity to hinge joints they can be very difficult to remedy in training. At the elbow we have 16 muscles that cross the joint and given its relatively small surface area this makes for a rather claustrophobic joint. With a lot of muscles crossing the joint, we of course then have several (strong) tendinous junctions. And, additionally, there are several major nerves and vascular structures that intersect the elbow.

Illustration of major muscles of the (R) forearm (Image via- Breaking Muscle)

When it comes to injuries at the elbow, generally speaking, we tend to see more chronic/overuse injuries than acute. Consider common ailments such as golfer’s elbow (medial tendonitis), tennis elbow (lateral tendonitis), and arthritis to name a few. When dealing with chronic/overuse injuries such as these, I’m always inclined to look above and below the joint itself. In my view, if we have chronic development it indicates to me that the supporting or surrounding structures haven’t been pulling their weight, thus overstressing the joint. The elbow, similar to the knee, is not really designed to accommodate torque- or valgus/varus stress. If we have compromised mobility/stability at the shoulder, in some capacity the elbow is then required to tolerate more rotational force to achieve similar degrees of collective freedom.

Illustration showing the relative position of the elbow (Image via- Clinical Gate)

Now, before anyone jumps to scold me, please note that this isn’t an inherent solution by any means, this is simply the first variable I typically look to with chronic injury cases. Similarly, I will look at the stability of the wrist as this is another complimentary relationship whereby a lack of wrist stability will inevitably require more work for the elbow. In addition to addressing stability/mobility deficits at the wrist/shoulder there are a few primary applications I’ve found successful with my athletes. Those being:

1.) Improve Grip Strength

-Grip strength is important not only for the forearm flexors, but also for neural stimulation

-Consider challenging grip strength from multiple positions, and with a variety of applications

-Pinch grip, fat grips, bands and battle rope all work great here

2.) Pronation/Supination

-Pronation/supination are needed for complete flexion/extension patterns

-Consider roles as primary and secondary movers (agonists/synergists)

-I get the most bang for my buck on using a variety of kettlebell bottom’s up work

3.) Triceps Strength

-The triceps are both an elbow and scapular muscle. Triceps strength is critical for elbow health not only with regard to complete extension, but also resting scapular position.

-Consider long-lever triceps work to emphasize elbows working as a stabilizer.

-Obviously no shortage of options here but see playlist above for my most utilized.

4.) Soft tissue/blood flow

-Ultimately the health and function of the elbow, no differently than anywhere else, will be governed by localized circulation, proprioception/nerve function and tissue quality. If the athlete is currently or recently coming off of injury, I strongly believe this is a non-negotiable part of training/treatment. For everyone else, I still feel these should be applied periodically throughout the training cycle.

-If referring out is what’s needed, then it’s what should be done. Deep tissue/cupping/ acupuncture/dry needling can all be tremendously helpful in restoring full health & function.

-As for therapeutic methods for strength coaches and self-care, I’m a big fan of Voodoo Floss, Katsu/Blood flow restriction, and buffer stimulation.

Image highlighting the major nerve supply to the arm and elbow. (Image via- Clinical Gate)

Working around elbow pain can be difficult, but there are a handful of strategies that can be utilized to minimize limitations and keep the athlete pain free. One thing I should be clear on is that when utilizing modifications to bypass or reduce stress on a particular area, in this case the elbow, it’s imperative that the pillars outlined above are being addressed. Be mindful that when using training modifications, we’re ideally only using them as a temporary means, not as permanent solutions. As such, be vigilant with the aforementioned restorative applications don’t fall into the trap of “no pain no problems”.

1.) Landmine for pressing (and a lot of pulling, too)

We all know my love/bias for the landmine (LM) is no secret, but I don’t know any way to describe it other than I wouldn’t use it so frequently if I didn’t see tremendous value. As it applies here, the LM specifically challenges the elbow complex due to the multiplanar nature of the LM set up. This creates a great stimulus for the pronator/supinator groups, and indirectly the demand for wrist stability (preventing roll) and shoulder mobility (providing ROM).

Another benefit to the landmine is allowing the athlete to “find their groove”. A major constraint to conventional barbell work {with elbow pain} is that the fixed nature of the barbell essentially locks the wrist down and doesn’t permit much deviation in path of motion or freedom of movement. With the landmine, the athlete can “circumvent” painful or weak points for the elbow and allow them to load heavier without setback. Speaking to the pulling benefits, I like the rep-to-rep variability that the LM provides which slightly changes the firing pattern in the upper arm/forearm. While this I suppose this is still a somewhat controversial approach, generally speaking I’m a big fan of the “rep without rep” concept for injury restoration.

2.) Accommodating Resistance

Band/chain tension is another training modality that I am a strong advocate of, and for a long list of reasons. Band tension provides a gradient stimulus throughout a given ROM, where the resistance is moderate at the start of a movement and highest at end range. This promotes an optimal stress/tension relationship by having the highest demand at the strongest point of the movement and vice versa. For instance, consider an athlete struggling to achieve full elbow extension, but not exactly limited by strength. This is a common situation for me, and utilizing a band or chain set up helps minimize the gap between undertraining (i.e., not loading heavy to avoid elbow extension irritation) and overstressing the area (i.e., excessive loading or demand on triceps).

Another major benefit here is removing the presence of a fixed load/lever, which can be a strict limiting factor when working around elbow pain. If the athlete is locked into a certain degree of fixed pronation/supination (i.e., barbell), apart from being uncomfortable for the athlete it can also dramatically reduce their ability to execute movement. By having them use band/chain only loading (or in addition to dumbbells/ kettlebells), the athlete can modify their hand and wrist position to accommodate for the elbow and still maximize the movement.

Lastly, accommodating resistance is a premier application for challenging the joint mechanoreceptors, which are designed to detect joint position and internal pressures in relation to external load and speed. I believe a wildly overlooked variable in the strength training world is joint proprioception and its direct influence on strength and function. In essence, we can improve muscular strength all day, and even to include soft tissue strength; however, if the joint mechanoreceptors haven’t been appropriately stimulated/ challenged, then I believe we will continue to see a diminishing return on investment. Because of the instability, perturbations, and movement variance that bands and chains provide, it stimulates these mechanoreceptors helping to recalibrate the system. This is a critical factor in injury restoration.

3.) Hand Position

I’ve already alluded to this a bit, but hand position is another variable of interest for managing elbow health. As it applies, I want to use what the athlete feels is most comfortable for our primary lifts and challenge them with what is the most deficient in their accessory work. For example, let’s say an athlete is coming off of a UCL tear and has had subsequent lingering medial elbow pain. Given the proximity of the UCL (medial condyle) they will likely have more difficulty (or pain) with a pronated or supinated grip but have no issues in a neutral hand position. As such, in earlier phases of rehab we would want to program mostly neutral with selective pronation/supination work. As they continue to regain full strength, the ratio would flip whereby we would want to exclusively challenge them in pronation/supination and reduce frequency of neutral grip.

4.) Some additional considerations for the elbow

-Be mindful of pressing & pulling volume, also remain cognizant of primary movements that indirectly place high stress on the elbow (i.e., overhead squats/lunges/carries)

-Use straps and/or wraps for main lifts. If I’m doing Hex Bar Deadlifts, I never want grip strength to be the limiting factor. In this case, use straps so the athlete can fully load the movement, then work grip strength independently. Wrist wraps can also be your friend on pressing movements to mitigate presence of elbow pain correlated to poor wrist stability.

-Compression garments, in my experience, can be tremendously helpful for managing elbow pain. For my athletes with arthritis/tendonitis, compression sleeves can be a game changer for alleviating constant, dull pain and irritation.

All in all, the elbow can be a challenging joint to work around, but don’t feel like your aimless or “just need to avoid it” during training. The most critical factor is that you address it with the help that’s needed, or in other words- don’t hesitate to refer out. Again, modalities like deep tissue massage, dry needling, and cupping among others can be the missing link between being in constant pain and being fully healthy. Don’t ignore things like soft tissue quality, localized blood flow and nerve function. No strength training or stretching will completely resolve the issue, it’s a part of the puzzle, but not the end all be all. Use a variety of tools and load applications, and contrast between utilizing where the athlete feels they are strongest and challenging them where they’re deficient. Inevitably there will be setbacks and disruptions, but your job as the coach is to find the tools and means necessary to give them the best opportunity for success. The elbow will be directly influenced by the wrist and shoulder, so be keen on managing those joints as well. And ultimately, the recovery will be a byproduct of time, so remain patient and stay focused on controlling the controllables.

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