Injury Profiles - Volume 1, Medial Epicondylitis

The pull-up bars are here, the pull-up bars are here! Hooray!

I know that we’re all very excited about the new pull-up bars in the gym, right? They’re very nice looking and certainly more accommodating than the old bars. Just ask Amy, who is soooo excited that she doesn’t have to drag over the 30” box to reach the bars.

This may also strike fear in the hearts of many, as well it should. I’m sure we are all experiencing just a bit of anxiety wondering what kind of torture Jeff and Laura are dreaming up with the new bars. We have gotten a small taste over the last couple of weeks, but rest assured there is more “fun” waiting for us from here on out. I can see it now:

17 Rounds for time
25 pull-ups
35 Ring Rows
50 Knees to Elbows
(Jeff, put down the pen. This was just a ludicrous example to illustrate a point, not a WOD recommendation)

We have been reacquainted with old friends, namely Helen, Cindy and J.T. I foresee some other old friends coming by soon in the near future to test our fitness – Fran, Murph and then there’s always Filthy Fifty.

While this is all very exciting, I think it’s important to put out one little word of caution. For most of us, this will be the first time we have done any significant bodyweight pulling exercises in several weeks. For the new people, this may be the first time you have ever done any bodyweight pulling exercises. Anytime you begin a brand new activity or return to an activity after a significant layoff, it’s critically important that you work your way into the activity gradually. Ignore this bit of advice and you are just asking for an injury.

Let’s take a few minutes to explore one of those possible injuries. Later, in another episode, we’ll look at other possible maladies that we expose ourselves to in our quest for “Elite Fitness”.

Medial epicondylitis, otherwise known as “golfer’s elbow” or “little league elbow” is a common elbow injury. In layman’s terms this injury is an inflammation/irritation of the tendons attaching to the medial epicondyle of the elbow. This injury is especially prevalent in sports and activities that have a strong grip requirement.

The medial epicondyle is the sharp, pointy, bump located on the medial side (inside) of the elbow. Stick your arm straight out in front of you with your palm turned up toward the ceiling, follow the inside of your arm down from your armpit toward your elbow and the first prominent bump you hit will be your medial epicondyle.

This “bump” is a common attachment point for several muscles that control your wrist and hand. Place your fingers on the soft tissues just past this bump and then make a tight fist. You will see and feel the muscles contract throughout the forearm and around the medial epicondyle. Now, keep that fist held tight and bend your wrist, pulling your hand up toward your elbow. You should see a lot more muscle action around the forearm and you should feel a lot more tension around the medial epicondyle. Now you understand why doing activities like pull-ups, knees-to-elbows, muscle-ups and ring rows can place a significant amount of stress on this important anatomical structure.

In the initial stages of medial epicondylitis you will likely experience a burning or aching sensation around the medial epicondyle during or immediately following heavy grip/pulling activities. If you ignore these early signs and push (or pull rather) through the pain, your symptoms will likely begin to linger for several hours after your workout and may begin to bother you with typical daily activities such as carrying a briefcase, pulling open a door or lifting a light item. If you press directly on the medial epicondyle it will probably quite tender to the touch. In more severe cases you may notice a small amount of swelling around the epicondyle and even some redness.

Recognizing the early signs and symptoms of medial epicondylitis and acting accordingly is the key to preventing this from becoming a long-term or severe injury. As soon as you begin to feel aching or burning around the medial epicondyle it’s time to take action. Just as when we first started our CrossFit journey, scaling and modifying activity is essential when dealing with an injury. Often times, just backing off for a few days and then gradually working back into it will be enough to allow the body to recover and begin the healing process. In addition to backing off, in the early stages it is also helpful to apply ice several times per day. A small bag of ice, or even frozen peas, applied to the medial epicondyle for 10 minutes will help reduce pain and prevent further inflammation.

Over the counter anti-inflammatories (aspirin, advil, motrin, ibuprofen, etc) can also be helpful in the early stages. Since I am not a physician, I can not prescribe or even suggest a prescription dose of anti-inflammatories, but it’s not hard to figure it out, just read the bottle. The key with taking anti-inflammatories is to take them regularly, as described on the bottle, for 7-10 days. If it’s feeling a lot better after a couple of days, it’s still advantageous to continue taking the meds for a full 7-10 days. It takes this long for the body to develop an actual anti-inflammatory response. In the first couple of days, the relief you are experiencing is likely due to decreasing activity and the analgesic (pain-relief) properties of the meds, the inflammation is probably still there.

Activity modification is the real key to success here. This is where the art of injury rehabilitation begins. It is important for you to remain as active as possible. Continue doing activities that involve gripping and pulling, but decrease the load or intensity so that you can accomplish these activities without significant pain. Try dead-hang pull-ups instead of kipping or ring rows instead of pull-ups. Scale your ring rows by backing up a couple of steps to decrease the resistance.

Applying stress to the healing tissues is essential to getting the scar that will form to align with the tissues in an appropriate manner. Without this stress the scar tissue can form a disorganized mass that can cause problems down the line. Stretching is another important element in the rehab process. When stretching be sure to stretch the muscles involved in wrist flexion, but also stretch the muscles on the opposite side of the forearm as well. (see pictures below. Note all stretches pictured are for the left elbow)

These first 2 stretches target the wrist flexors which attach to the medial epicondyle. For the second stretch, notice that I add a little twist toward my pinky. This little twist really helps focus the stretch right along those flexors which run in a diagonal pattern up the forearm.

While it is obviously important to stretch the wrist flexors, it is equally as important to stretch the wrist extensors on the opposite side of the forearm. Overtight wrist extensors may have actually contributed to your problem. The wrist extensors attach to the lateral epicondyle on the opposite side of the elbow of the medial epicondyle. The second stretch is a little tricky, but it's a great stretch. Stick your left arm straight out in front of you and rotate so that your palm is facint out toward the left. Bring your right hand up from underneath and interlock your fingers together. Keeping the fingers locked together pull your wrist back which will pull your left wrist into flextion. You should feel a good stretch along the back of the forearm running diagonally toward your lateral epicondyle.

If you have been dealing with pain for a while, longer than a few weeks, then you are likely no longer dealing with an inflammatory situation. You have likely progressed on the next stage of injury, the chronic stage which is more appropriately termed tendinosis. At this stage, continuing anti-inflammatory strategies will not likely buy you long term relief. The damaged tissues have likely begun to heal, but have done so in an inappropriate manner. The key to long term recovery is to get the tissues to remodel and form appropriate scar tissue that aligns with the normal tissue. There is a good amount of research that supports the use of eccentric loading (think negatives) to facilitate this remodeling. To perform eccentric loading for the wrist flexors, you’ll want to use a fairly heavy weight. Extend your elbow completely with your palm facing up. Hold the weight in your hand and use the other hand to passively lift your hand and weight toward the ceiling. Once your wrist is fully flexed, slowly lower the weight using only the hand of the injured elbow. Your goal should be to perform 2 sets of 15 reps, 2 times per day. It is expected that during this exercise you should experience a fair amount of discomfort. As long as it is not severe or debilitating, it’s okay. It will get better with time. If you get to the point that you can perform the 2 sets of 15 reps without difficulty or pain then it is time to bump up the weight. This process will likely take several weeks, but you should see steady improvement in your pain level and strength. Ice after performing these activities for pain relief. Continue to modify your activities in the gym as appropriate.

Of course with a bit of prudence and good judgment this can hopefully all be avoided. Remember, the beauty of CrossFit is that it is SCALABLE. Just because you did all Rx pull-up bar exercises previously, doesn’t necessarily mean you should just assume that you can jump right back into them. A gradual progression is always the best policy. Push yourself but listen to your body.

Stay tuned for the next installment of pull-up bar injuries.