In my experience, elbow pain can be a tricky issue to deal with for a lot of people. Usually the experience goes one of two ways:

1. Person gets treatment to the elbow itself with a combination of soft tissue work (massage, ART, Graston, lacrosse ball) and exercises (eccentric wrist curls etc). BOOM. EASY. They are back in action in a matter of  days or weeks. 

OR

2. Person tries every combination of possible treatments mentioned above as well as NSAIDs, pain patches, ultrasound, medications, cortisone injections, prolonged rest, you name it. Person gets little to no results and continues to suffer for months to years.  

Scenario #1 is actually not so common. So what is that about? Why do we get results some of the time but not all the time? What is different in these two situations?

vian at BIW

Climbers and non-climbers alike often ask me for advice or seek treatment for their elbow pain in my office. Many times these people have tried everything and have had the problem for months if not years.

As a general rule of thumb, many common injuries that seem to be relentless and non-responsive to treatments may actually be coming from elsewhere in the body.

Some “injuries” may actually just be a symptom and not the actual injury or source of dysfunction.

A commonly misdiagnosed “injury” that I have seen in the elbow involves lateral epicondylitis (tennis elbow). 

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The C6 nerve root exits between the 5th and 6th vertebrae which are two of the most commonly injured areas in the cervical spine (aka the neck) and most often involved in cervical radiculopathy.  Any radiculopathy from this nerve root can cause weakness in wrist extension.  I have seen even a subtle loss of strength of wrist extension cause a raging lateral epicondylitis.  Sometimes this weakness is so subtle that the person doesn’t even realize they have weakness until it is too late. The person continues to function and use their hands with this weakness and ends up overloading the area.

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So, we can treat the heck out of the lateral epicondylitis, but if we don’t solve the nerve root issue at the cervical spine we will never regain the wrist extension strength that is needed to decrease the symptoms of lateral epicondylitis.

After getting frustrated with my first few epicondylitis patients years ago I learned that many times epicondylitis is actually being caused by cervical radiculopathy.

referred-pain

A new study published in the journal Sports Health sought to estimate the actual prevalence of medial epicondylitis among patients with cervical radiculopathy.  The authors evaluated 102 patients with documented cervical radiculopathy and found that more than half (55 to be exact) also had medial epicondylitis.  None of these patients had a documented cause of the epicondylitis.  The vast majority (80%) of these patients had C6 and C7 radiculopathy, the remaining 20% had C6 radiculopathy.

These findings make a good argument for radiculopathy being a potential cause of epicondylitis and I think that the results can be extrapolated for lateral epicondylitis.  If muscle weakness or imbalance occurs to the wrist extensors and flexors, which are innervated by C6 and C7, overuse and eventual tendinopathy are likely to occur.

This could be a very large reason why epicondylitis has traditionally been such a challenging pathology to treat.  We can treat the symptoms but will not make any lasting gains without treating the source – the neck. We need to take a step back and think of the bigger kinetic chain principle.  Perhaps we are only treating the symptoms and not the true source of the dysfunction when we treat the elbow.

Based on this, I make it standard practice to clear the cervical spine when I am evaluating patients with epicondylitis.

If you have elbow pain (or any injury for that matter) that has not resolved you are probably dealing with a symptom and you need to seek professional help to figure out where the dysfunction is that is causing your elbow pain.

At least get a diagnosis so you know what you are dealing with before wasting time Googling symptoms and trying to self treat. Trust me. It will save you time, money and suffering in the long run.

Dave MacLeod makes an excellent point in his new book Make or Break

“The body is extremely complex and it is rarely possible for a non-medic to confidently exclude possible diagnoses. An example of this is nerve compression syndromes of the back and neck which mimic exactly the symptoms of elbow tendon pain.”  

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COMING NEXT…how to treat elbow pain and what I do with elbow pain patients.