Medial + Lateral Epicondylitis
Medial epicondylitis occurs more in climbers than lateral epicondylitis howeve,r both occur and are among the more common injuries in the climbing world. Often presenting as a localized pain on the medial and lateral epicondyle, however, pain radiating down the forearm into the forearm can be present as well. Moreover, some cases will present with decreased strength in the forearm muscles.
Anatomy
Medial Epicondylitis
Medial Epicondylitis (Golfers Elbow) is present at the tendinous attachment of forearm flexors, the common flexor tendon, located at the medial epicondyle (the bony landmark at the inside of your elbow). Muscles that perform wrist flexion and pronation are located here, commonly, pain will be present in these motions. Commonly, the muscles of irritation are the Pronator Teres and Flexor Carpi Radialis.
Lateral Epicondylitis
Lateral Epicondylitis (Tennis Elbow), similarly to medial epicondylitis, pain will be present near or on the epicondyle on the lateral side of the elbow. This is the common attachment point for the flexors of the forearm to attach muscles that promote extension, supination and ulnar deviation of the wrist. Although less common in climbers, the injury is similar in the degradative process and follows the mechanism of injury.
Method Of Injury
Often, the cause of these injuries is repetitive overstrain at the attachment of the forearm extensors (lateral side) and flexors (medial side). This repetitive overstrain causes microtraumas leading to inflammation and degenerative changes, eventually leading to tendinopathy.
Secondly, these injuries can be triggered due to a muscle imbalance between the forearm flexors and extensors, which is often due to a lack of training of the antagonist group of muscles, which is very common in climbers.
Although these injuries are commonly due to repetitive overuse of the muscles and are considered to be a chronic injury, acute loads can trigger aggravation of the tendinous attachment leading to degenerative changes and inflammation.
Assessment
Visual
The elbow can present with redness or inflammation around the area of pain, however, this is typically not present or unremarkable in long-standing cases.
Palpation
Tenderness to palpation 5- 10 cms below the tendinous attachment of the medial epicondyle (or lateral epicondyle).
Movement
Medial Epicondylitis
Active and resisted wrist flexion, radial deviation and pronation. During these tests, the elbow should be flexed at a 90-degree angle to help isolate the pronator teres.
We can also test with passive range of motion, putting the arm into 90 degrees of flexion, with wrist extension, passively moving the forearm into extension, while keeping the wrist in extension.
Lateral Epicondylitis
Active and resisted wrist extension with a straight arm. This is known as the Mill’s Test.
Recovery
Suggested recovery follows the principles of unloading, mobility, and strengthening, followed by a return to sport. Both lateral and medial epicondylitis follow this structured approach to rehabilitation. As always, it is important to note that you should avoid any exercises that trigger a pain response. It is always best to consult a medical professional for proper diagnosis and rehabilitation guidance.
Lateral Epicondylitis
Deloading
We are interested in deloading the common extensor tendon, with the hopes of reducing the inflammation response and stimulating the early stages of healing. We can achieve this by taping or bracing the elbow.
Taping
Diamond Deload
Although research on the long-term effects of pain reduction and increased grip strength is conflicting, the Diamond Deload Tape job has shown positive results for immediate pain relief. However, due to the nature of this taping method, it is not recommended for use during physical activity. Instead, a bracing approach is advised while climbing.
Bracing: Counter Force
Bracing applies light pressure across the common extensor tendon, where the forearm extensor muscles attach. The goal of a padded brace is to distribute force in the affected area, reducing strain. While this is not a long-term solution, it has been shown to provide short-term relief (less than six weeks). For lasting recovery, physiotherapy interventions have been proven to be more effective in the long term.
Mobility
Massage
Self-massage or rolling of the muscles attaching to the lateral epicondyle (extensors) can help reduce built-up tension. By loosening these muscles, massage may also decrease stress on the tendinous attachment, promoting relief. Avoid massaging and or rolling directly to the lateral epicondyle (the large bony point on the outside of your elbow)
This can be performed with a lacrosse ball and or your other hand, performing 2-3 a day for up to 8 minutes.
Stop immediately if you experience any tingling or weakness further down the arm.
Tendon Gliding
Tendon gliding is meant to run the tendons through the full range of motion, promoting healing and increased blood flow. In order to do this, we want to put the forearm through its full range of motions.
This exercise is explained in depth at 3:58 in this Video
Strengthening
Loading the tissue is a critical component of the recovery process, but it’s important to start with light loads and gradually adjust. When selecting a weight for exercises, begin lighter than you think is necessary and modify based on your 24-hour check-in:
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Was there more than 2/10 pain during the exercise?
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Was there pain the next day?
If either answer is yes, reduce the load or volume.
Additionally, be mindful of frequency. Since lateral epicondylitis is an overuse injury, doing too much too soon can slow progress or even cause setbacks. Gradual and controlled progression is key to effective healing.
Thera-band Eccentrics
Wrap a thera-band around the back side of your hand and anchor the opposing end under your foot while in a seated position. Rest your forearm on top of your thigh so that only your hand and wrist are not supported. From a fully extended wrist position slowly lower into a fully flexed position. 36 seconds - 1:17 in the Video
Extensor Wrist Curls
Using a small dumbbell, we can perform an extensor wrist curl. While holding the weight, anchor your forearm to a solid surface, your thigh, a bench, or a bouldering mat, allowing for your wrist to hang over the edge. In a slow and controlled fashion, move from a fully flexed wrist position to a fully extended wrist position and back. Perform this movement for roughly 15 reps and 3 sets once a day.
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Medial Epicondylitis
Deloading
The deloading process for medial epicondylitis is similar to that of lateral epicondylitis, but this injury occurs on the medial side of the elbow, where the common flexor tendon is located. Like its lateral counterpart, medial epicondylitis also has a tape job recommended for daily relief and a bracing mechanism that is better suited for activities that may aggravate the injury.
Bracing
Bracing applies light pressure across the common flexor tendon, where the forearm flexor muscles attach. The goal of a padded brace is to distribute force in the affected area, reducing strain. While this is not a long-term solution, it has been shown to provide short-term relief (less than six weeks). For lasting recovery, physiotherapy interventions have been proven to be more effective in the long term.
Mobility
Property of Releigh Hand Surgery, Joseph J. Schreiber
Massage
Self-massage or rolling of the muscles attaching to the medial epicondyle (flexors) can help reduce built-up tension. By loosening these muscles, massage may also decrease stress on the tendinous attachment, promoting relief. Avoid massaging and or rolling directly to the medial epicondyle (the large bony point on the inside of your elbow)
This can be performed with a lacrosse ball and or your other hand, performing 2-3 a day for up to 8 minutes.
Stop immediately if you experience any tingling or weakness further down the arm.
Dynamic Strethcing
The goal of this exercise is to stretch the forearm flexors, helping to release tension through the muscle and reduce pain in the medial epicondyle.
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Start with arms straight out at shoulder height, bring your palms together and maintain light pressure with your fingers spread apart.
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Pull your wrists towards your stomach while keeping your palms together
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Rotate your hands down so that your fingers point to the ground
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Rotate your hands upward so that your fingers point to the sky
Repeat for 3 sets of 12 once a day
Strengthening
Loading the tissue is a critical component of the recovery process, but it’s important to start with light loads and gradually adjust. When selecting a weight for exercises, begin lighter than you think is necessary and modify based on your 24-hour check-in:
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Was there more than 2/10 pain during the exercise?
-
Was there pain the next day?
If either answer is yes, reduce the load or volume.
Resisted Wrist Rotation
Wrap a Thera-Band around the palm of your hand and anchor the opposing end under your foot while in a seated position. Rest your forearm on top of your thigh so that only your hand and wrist are not supported. From a neutral wrist position with your palm facing up, rotate so that your palm is facing the floor.
Perform 3 sets of 15 reps once a day
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Resisted Wrist Flexion
Wrap a Thera-Band around the palm of your hand and anchor the opposing end under your foot while in a seated position. Rest your forearm on top of your thigh so that only your hand and wrist are not supported. With your palm facing the sky, perform flexion of the wrist, then return to a slightly extended wrist position.
Perform 3 sets of 15 reps once a day
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Return To Sport
When returning to climbing, it is important to avoid suboptimal positions that may place excessive stress on the recovering tissues, potentially delaying recovery. Remember that every recovery is different, and there is no set timeline for full healing.
As you progress back into climbing, self-check-ins are crucial—both immediately after each session and the following morning—to assess any pain or soreness. If you experience pain during or after a session, it is a sign that you may need to reduce your climbing load and slow down the recovery process to prevent setbacks.
Sub-Optimal Positions: To Avoid While Climbing
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Grips with an extended wrist position
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Moves that cause your elbow to move away from the wall
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Hand jams in wide cracks
Optimal positions: These positions are less likely to produce a force that will cause irritation and worsen your condition.
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Keeping a neutral wrist while climbing
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Keep your elbow under your wrist
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If Crack Climbing, Twist your wrist inside of wide cracks
Medial Epicondylitis
Lateral Epicondylitis
When returning to climbing, it is important to avoid suboptimal positions that may place excessive stress on the recovering tissues, potentially delaying recovery. Remember that every recovery is different, and there is no set timeline for full healing.
As you progress back into climbing, self-check-ins are crucial—both immediately after each session and the following morning—to assess any pain or soreness. If you experience pain during or after a session, it is a sign that you may need to reduce your climbing load and slow down the recovery process to prevent setbacks.
Sub-Optimal Positions: To Avoid While Climbing
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Over-gripping holds
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Gripping holds with a flexed wrist position
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Hips sagging away from the wall
Optimal positions: These positions are less likely to produce a force that will cause irritation and worsen your condition.
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Grip holds with a neutral wrist
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Don't overgrip hold
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Bring your hips closer to the wall
References
Schöffl, V., Schöffl, I., Lutter, C., & Hochholzer, T. (2022). Climbing medicine: A practical guide. Springer International Publishing Springer.
Vagy, J. (2018). Climb injury-free: A proven injury prevention and rehabilitation system. The Climbing Doctor.