Latest / The Driven Athlete / The Elbow Is The Victim, Not The Culprit | Ep 112

Transcript

The Elbow Is The Victim, Not The Culprit | Ep 112 · The Driven Athlete

• 0:00
  SPEAKER_00: If you're a driven, active person who wants to reach and pursue a higher quality life with some ambition, then guess what?
• 0:06
  SPEAKER_00: This podcast is for you.
• 0:08
  SPEAKER_00: This is the Driven Athlete Podcast.
• 0:12
  SPEAKER_00: What's up, y'all?
• 0:13
  SPEAKER_00: Welcome back to the Driven Athlete Podcast.
• 0:16
  SPEAKER_00: I want to talk about uh the medial elbow, all right, the inside component of the elbow.
• 0:21
  SPEAKER_00: If you look right here like this, all right.
• 0:23
  SPEAKER_00: So that's the inside of the elbow for throwers, all right.
• 0:27
  SPEAKER_00: So baseball, um, volleyball, even the cross, and then uh uh for golf and it and also tennis, but uh for golf as an example, they would call it golfer's elbow, all right.
• 0:41
  SPEAKER_00: But um, this is kind of a different thing.
• 0:43
  SPEAKER_00: Okay, so imagine like a young baseball player has elbow pain on the inside of the elbow, you know, there'd be risk of what we don't want to have happen, Tommy John, okay.
• 0:53
  SPEAKER_00: Tommy John injury, Tommy John surgery would be the next result.
• 0:56
  SPEAKER_00: And that's just coined after a uh player named Tommy John who um as the the procedure is named and the the issue is that is named after, but the the UCL is the ligament that connects from the medial epicondyle of the humerus to the ulna.
• 1:15
  SPEAKER_00: All right.
• 1:16
  SPEAKER_00: And um, it's called the ulnar collateral ligament, and it has a couple bands of that ligament, and the anterior band of the UCL is the one that gets frayed and some micro-tearing and it fails with a lot of and it so it tears with a lot of um repetitive stress placed on the inside of the elbow like that.
• 1:37
  SPEAKER_00: All right, they call it valgus stress.
• 1:39
  SPEAKER_00: Valgus would be like if you um bent your elbow inwards and your hand away from your body simultaneously.
• 1:46
  SPEAKER_00: So imagine somebody throwing a baseball at very high velocity, the inside of their elbow advances forward and their wrist and hand it goes backwards.
• 1:56
  SPEAKER_00: And that's like the layback or late caulking phase of the throw to like when they accelerate to the throw.
• 2:03
  SPEAKER_00: And that just causes a lot of stress on the medial elbow joint.
• 2:07
  SPEAKER_00: And a passive structure that takes a lot of that stress is the anterior band of the UCL, all right, of the ulnar collateral ligament.
• 2:16
  SPEAKER_00: And repetitively over time, with not the best mechanics and undue stress continually with high velocity, um, that leads to that getting broken down.
• 2:27
  SPEAKER_00: And some of the other structures in the area of the elbow can also get irritated and painful and broken down as well, all right.
• 2:33
  SPEAKER_00: And um the large muscle structure in that area is the flexor pronator mass, uh, the FPM.
• 2:40
  SPEAKER_00: And it's actually a handful of muscles, okay, that um all insert there.
• 2:46
  SPEAKER_00: Okay.
• 2:46
  SPEAKER_00: So there's uh eight muscles that attach right on the medial epicondyle of the elbow that are influential and law that all connect in that one or uh origin or insertion point on the elbow.
• 2:59
  SPEAKER_00: Um, and that's a very vulnerable area for repetitive stress and tension at the insertion point, and that can cause like a tendinitis.
• 3:08
  SPEAKER_00: All right.
• 3:08
  SPEAKER_00: So that is golfer's elbow, medial epicondylitis or medial epicondylopathy, a pathology or issue of the insertion point of those flexor muscles as they insert to the elbow.
• 3:20
  SPEAKER_00: Okay.
• 3:21
  SPEAKER_00: That would be like a tendonitis.
• 3:22
  SPEAKER_00: And that comes also with repetitive valgus and stress of pulling and gripping, grasping exercises for the elbow.
• 3:30
  SPEAKER_00: And that would be like tennis, golf, lacrosse, pickleball, racket sport, squash, paddle ball, paddle, um, all that like racket sports.
• 3:38
  SPEAKER_00: So a lot of like swinging and wristy motions involved with hitting a ball to play sport.
• 3:44
  SPEAKER_00: Another common uh population with golfers' elbow would be like weightlifters doing pull-ups or chin-ups and rows.
• 3:52
  SPEAKER_00: Um, because it's a lot of repetitive, um, a lot of tension and tensile strength requirements on the insertion point of that group of muscles on the medial elbow right here.
• 4:05
  SPEAKER_00: All right.
• 4:06
  SPEAKER_00: And uh that gets broken down over time.
• 4:08
  SPEAKER_00: The question would be like, that gets broken down because it's overwhelmed and stressed, because other structures aren't contributing enough.
• 4:15
  SPEAKER_00: And those flexor muscles of the wrist are doing more than they can handle.
• 4:19
  SPEAKER_00: All right.
• 4:19
  SPEAKER_00: So that would be an imbalance of recruitment and strength.
• 4:22
  SPEAKER_00: And that imbalance of muscle strength and recruitment um is inherently uh it's just learned.
• 4:29
  SPEAKER_00: Like people, that's just how they learned how to move and groove.
• 4:31
  SPEAKER_00: So as a physical therapist, we intervene to make sure that things are uh the mobile, the mobility of the wrist, the elbow and the shoulder and the scapula are moving well, but then also the muscles that connect to the scapula and shoulder are contributing enough to offset the requirements of the elbow and the elbow is not constantly overcompensating.
• 4:49
  SPEAKER_00: All right, so that overcompensation and compensation patterns leads to chronic um uh overwhelm, and then that gets broken down over time.
• 4:57
  SPEAKER_00: And then the straw that broke the gamble's back is when people have symptoms.
• 5:00
  SPEAKER_00: Like, I don't know what's going on.
• 5:02
  SPEAKER_00: My elbow is really tender.
• 5:03
  SPEAKER_00: All right, this that'd be golfer's elbow.
• 5:05
  SPEAKER_00: So back to the thrower, though, all right, that's a different story.
• 5:09
  SPEAKER_00: So the structures that get irritated there, um, passively, a passive ligament, all right, meaning like it's not an actively contracting tissue.
• 5:18
  SPEAKER_00: It's just, it's just stationary, it's just a passive ligament uh tendon.
• 5:21
  SPEAKER_00: Um, sorry, it's a passive ligament that doesn't actually actively contract.
• 5:25
  SPEAKER_00: All right, like a muscle and a tendon is an active dynamic structure that contracts and relaxes, but ligaments don't.
• 5:32
  SPEAKER_00: All right, so it's a passive structure.
• 5:33
  SPEAKER_00: That's why we say that.
• 5:35
  SPEAKER_00: And the anterior band of the UCL is what gets chronically overstretched and strained, and that can lead to micro-tearing, inflammation, irritation, and then eventually maybe a more major tearing that would require surgical intervention to repair, and that would be Tommy John.
• 5:52
  SPEAKER_00: So the question would be like, but why?
• 5:53
  SPEAKER_00: Why is it that some throwers have medial elbow pain throughout the season and then other throwers don't?
• 6:00
  SPEAKER_00: And I, in my opinion, this is just my thoughts.
• 6:05
  SPEAKER_00: Saying overuse is a comp out answer.
• 6:08
  SPEAKER_00: All right, that's just that's lazy.
• 6:09
  SPEAKER_00: It's a lazy answer.
• 6:10
  SPEAKER_00: Oh, it's overuse.
• 6:11
  SPEAKER_00: All right, you're doing too much.
• 6:12
  SPEAKER_00: Okay, yeah, dude.
• 6:13
  SPEAKER_00: Like okay, of we they're probably overwhelming the tissue.
• 6:17
  SPEAKER_00: We know that.
• 6:18
  SPEAKER_00: But if it was overuse from throwing too much, then why aren't all of his teammates or her teammates also experiencing the same medial elbow pain at the same time in the season?
• 6:27
  SPEAKER_00: If they're all throwing the same volume or similar, it's because this one athlete's doing something different.
• 6:33
  SPEAKER_00: All right.
• 6:33
  SPEAKER_00: And we have to investigate and uh dive into what is what are they doing differently that's making these symptoms manifest through the elbow and expressing in the elbow.
• 6:44
  SPEAKER_00: Um, it's because the medial elbow is overwhelmed, right?
• 6:47
  SPEAKER_00: It's good, it's overcompensating, um, or there's too much stress placed on the elbow for that throwing motion.
• 6:54
  SPEAKER_00: What are they doing different then?
• 6:56
  SPEAKER_00: All right.
• 6:56
  SPEAKER_00: And usually what we find, the irritated structure, people want to know like what's painful is the UCL and then the flexor protein or mass, that muscle, uh, that group of muscle flexor muscles in the wrist that connect to the elbow are guarded and tense and over uh are strained as well.
• 7:13
  SPEAKER_00: Like there a lot of overwhelm is replaced is is uh laid on top of required upon them.
• 7:19
  SPEAKER_00: Um, but usually the medial elbow for throwers is getting lit up twofold.
• 7:25
  SPEAKER_00: They're lacking enough shoulder, external rotation, range of motion, and poor mechanics.
• 7:32
  SPEAKER_00: All right, so not the best mobility distribution, right?
• 7:35
  SPEAKER_00: Range of motion, mobility throughout the whole arm, the shoulder would be the main component that's not moving enough into external rotation.
• 7:44
  SPEAKER_00: And then the second thing would be not the best mechanics.
• 7:46
  SPEAKER_00: So the force production of like where is the force coming from to throw the ball really hard.
• 7:52
  SPEAKER_00: If this particular athlete is only using their arm muscles to make that happen, um, what do you think is gonna and they're not using their core, okay, and their trunk and their pelvis, rotation and their hips, all right, to create the rotational torque to create power, and they're only using the muscles in their arm, what do you think is gonna break down, right?
• 8:11
  SPEAKER_00: Their arm's gonna break down, all right.
• 8:12
  SPEAKER_00: And a very vulnerable structure that is gonna take a lot of the brunt uh with the force is a valgus moment or a valgus stress on the medial elbow.
• 8:24
  SPEAKER_00: And the structures that prevent valgus stress, all right, it's gonna be the anterior band of the UCL, and that's what's gonna fail.
• 8:29
  SPEAKER_00: So do it long enough with the poor mechanics and uh enough force and not the best um range of motion distribution to distribute the force throughout the shoulder girdle and the arm and your trunk and your pelvis and your hips, dude.
• 8:46
  SPEAKER_00: That thing's gonna get over.
• 8:47
  SPEAKER_00: That thing's gonna get broken down away and loot up.
• 8:49
  SPEAKER_00: So what's the solution then?
• 8:51
  SPEAKER_00: How do we okay?
• 8:52
  SPEAKER_00: If that's the lens, then how do we solve it?
• 8:54
  SPEAKER_00: Well, number one, the elbow is the victim.
• 8:57
  SPEAKER_00: It's not the problem.
• 8:58
  SPEAKER_00: So we're not gonna crush, you know, just needling and soft tissue and cupping and crushing elbow, strengthening things.
• 9:05
  SPEAKER_00: Like, of course, we didn't work on that stuff, but with this lens, the elbow is not the problem, it's actually the victim.
• 9:13
  SPEAKER_00: So um we need to play damage control with the elbow and do some motions, lotion, blood flow exercises to facilitate the healing process while also getting it to settle down, all right, for irritability and sensitivity.
• 9:26
  SPEAKER_00: And then uh we definitely need to intervene to the shoulder.
• 9:29
  SPEAKER_00: All right.
• 9:30
  SPEAKER_00: So, first thing I'm gonna investigate is what does the pure rotation and the external rotation of their shoulder joint look like?
• 9:39
  SPEAKER_00: And usually it's not as good as it needs to be, okay?
• 9:42
  SPEAKER_00: So um their elbow is overcompensating, okay.
• 9:45
  SPEAKER_00: Um, the next one will be their scapula.
• 9:48
  SPEAKER_00: You know, they're getting enough upward rotation and retraction for the overhead throw position.
• 9:55
  SPEAKER_00: And usually, no, all right, that's usually also a faulty thing that we find.
• 9:59
  SPEAKER_00: Third thing I'm gonna look at is um the stability and strength of their subscapularis, which is a rotated cuff muscle on the front, on the ventral side of their scapula, okay, that connects on the spans across the front part of the shoulder joint, and that just prevents excessive anterior translation of the shoulder.
• 10:17
  SPEAKER_00: So um, if somebody's lacking, this is the recipe, okay.
• 10:20
  SPEAKER_00: We see this a lot.
• 10:21
  SPEAKER_00: If somebody's lacking pure external rotation of the shoulder, okay, can't rotate back well enough, their shoulder joint's gonna advance forward or anteriorly excessively to make up for that.
• 10:32
  SPEAKER_00: All right, and that can cause anterior shoulder pain or posterior impingement.
• 10:36
  SPEAKER_00: Um, and then the medial elbow is gonna get overwhelmed, and they're lacking um rotation within their trunk and their pelvis and their hips, okay?
• 10:45
  SPEAKER_00: And we would call that sequencing.
• 10:46
  SPEAKER_00: All right.
• 10:47
  SPEAKER_00: So, like when somebody produces a strong throw force and they are in their wind up and they're about to throw the ball, what is rotating first?
• 10:58
  SPEAKER_00: The goal would be their pelvis, all right, their hips, their pelvis needs to rotate and open up to begin the process sequence first, followed by the trunk, followed by the shoulder, and then uh that allows like a solid layback position, which is like all the way back to an acceleration phase, to then the follow-through for the throw.
• 11:20
  SPEAKER_00: Okay, so if you're following me, layback is like if you ever seen a picture of a a baseball pitcher, like a major leaguer, and they're um about to throw the ball and they're at full stride, and the ball is like way behind them, and their arm is rotated backwards like 150, 60 degrees, right?
• 11:38
  SPEAKER_00: That's like a ton of extra rotation.
• 11:40
  SPEAKER_00: Um, that's layback, and that range of motion is necessary, all right.
• 11:44
  SPEAKER_00: It's a necessary adaptation for throwers that the bone of the humerus rotates more into retroversion, and the soft tissue of the musculature and the joint capsule also grows in that fashion over many, many years of throwing that um enables the shoulder to adapt to allow more external rotation of the shoulder joint.
• 12:11
  SPEAKER_00: Okay.
• 12:13
  SPEAKER_00: That's necessary and good.
• 12:15
  SPEAKER_00: All right.
• 12:15
  SPEAKER_00: Have you ever heard of GERD, G-I-R-D?
• 12:17
  SPEAKER_00: That's glenohumeral internal rotation deficit.
• 12:21
  SPEAKER_00: So they're gonna have GERD, but that's a good thing for throwers.
• 12:25
  SPEAKER_00: They need GERD, all right?
• 12:27
  SPEAKER_00: They actually need more external rotation.
• 12:30
  SPEAKER_00: All right.
• 12:30
  SPEAKER_00: I'm I'm not gonna stretch.
• 12:32
  SPEAKER_00: Do I'm not gonna do a sleeper stretch?
• 12:34
  SPEAKER_00: I'm not gonna bring them into more internal rotation and say, like, that's the reason why your elbows messed up or you're having shoulder pain as a thrower.
• 12:43
  SPEAKER_00: That's they actually most of the time they need more ER.
• 12:47
  SPEAKER_00: They need more of the external rotation.
• 12:49
  SPEAKER_00: They need like 150 to 160 degrees at layback with all the movement components.
• 12:56
  SPEAKER_00: Okay.
• 12:56
  SPEAKER_00: And we would call that like full layback position.
• 13:00
  SPEAKER_00: Um, we need thoracic spine rotation and extension, um, scapular retraction and some upper rotation, and pure shoulder joint external rotation.
• 13:14
  SPEAKER_00: All right, so those three things, and we would call that MER, the M-E-R, the max external rotation.
• 13:20
  SPEAKER_00: All right, and that comes from those three components that allows a pitcher in like baseball, like that poster, like a picture I'm talking about, where they're at full layback when their arms way back in full stride and their arms bent like all the way backwards.
• 13:33
  SPEAKER_00: Those three components is what allows that to happen.
• 13:35
  SPEAKER_00: And that's a good thing.
• 13:36
  SPEAKER_00: We need to facilitate that, that's safer for the shoulder and the elbow.
• 13:40
  SPEAKER_00: So a lack of those components leads to the elbow taking the brunt of a lot of the stress of the throw, and that can cause breakdown of the UCL.
• 13:50
  SPEAKER_00: It also messes with okay, if you're ever see an anatomy picture of the elbow, all right, the cup component, like the tip of your elbow, is called your elecronon process.
• 14:01
  SPEAKER_00: So the elecronon is like a cup that um rotates um over the humerus, okay, over the trochly of the humerus.
• 14:11
  SPEAKER_00: And um with excessive valgus forces, the ulna and the elecronon shifts laterally and medially.
• 14:19
  SPEAKER_00: All right, and that can cause what they would call kissing lesions of the bone of the alecronon tip because it's um getting altered and more of a lateral direction that is um causing a kissing lesion on the electro, the tip of the electronon as it abuts against the trochlea of the humerus.
• 14:37
  SPEAKER_00: And over time, that can also cause stress fractures in uh the olecronon or the distal humerus, all right, just from breakdown, all right, from excessive um a lot of stress, high velocity with with poor mechanics, and then you can say yes, overuse, as in like it was just a lot of repetitions.
• 14:59
  SPEAKER_00: It was just overwhelming volume, overwhelming volume with not the best mechanics, compounded over many episodes, and that leads to like, I don't know what happened when my elbow hurts, right?
• 15:11
  SPEAKER_00: Or even worse, like um the straw the bullet came up's back when uh elbow like hit the pitcher has his elbow pop.
• 15:18
  SPEAKER_00: All right, like I just like that's just fail absolute failure moment of um the ligament, okay, of the UCL.
• 15:25
  SPEAKER_00: So those are all the components we're looking at, right?
• 15:27
  SPEAKER_00: With uh the medial elbow for a thrower.
• 15:29
  SPEAKER_00: Like if the medial elbow hurts, the painful structures are usually the UCL band, the medial joint line, the capsule, okay.
• 15:37
  SPEAKER_00: The flexor protein or mass can be guarded intense.
• 15:40
  SPEAKER_00: The elecronon tip can be irritated of the bone because it's um abutting against the trochlea of the humerus with the altered valgus mechanics.
• 15:49
  SPEAKER_00: Um, and that's what's painful.
• 15:51
  SPEAKER_00: But it's a victim because they're not having enough shoulder external rotation.
• 15:56
  SPEAKER_00: The scapula isn't retracting and upperly rotating well enough at layback into mid-acceleration of the throw process.
• 16:04
  SPEAKER_00: Maybe what's investigated their thoracic spine, it's not rotating or extending well enough at layback as well.
• 16:09
  SPEAKER_00: Um, and then they're having an issue with sequencing.
• 16:12
  SPEAKER_00: Okay, so strength.
• 16:14
  SPEAKER_00: Core, pelvis, trunk rotation, initiating the movement for the actual torque of creating the throwing moment.
• 16:21
  SPEAKER_00: All right, glutes play a role with that, and the core plays a role with that.
• 16:24
  SPEAKER_00: Um, enough hip mobility plays a role with that.
• 16:26
  SPEAKER_00: So we're gonna investigate hip mobility.
• 16:29
  SPEAKER_00: Okay, and then um some of the strength in the shoulder joint, like the subscapularis is a key player as well, just to prevent altered mechanics in the shoulder with that aggressive throwing motion at full layback or late caulking to mid-acceleration where they're actually producing the force.
• 16:45
  SPEAKER_00: So they need to produce more force with their core and their trunk, their pelvis and their glutes.
• 16:50
  SPEAKER_00: Enough hip mobility is important, enough shoulder mobility is important, and then the sequencing of what rotates next to next and next, and the sequence of rotational uh force and torque.
• 17:00
  SPEAKER_00: Um, or a lack thereof, they're only using their arm, and their arm is too is muscling the throw, is what we would say.
• 17:08
  SPEAKER_00: And um, they're also short arming it because they're lacking rotation range of motion in their arm.
• 17:13
  SPEAKER_00: And uh that over time makes the medial elbow components break down enough to the point where if it fails and there's enough structural damage to the ligament, then maybe surgery would be indicated.
• 17:25
  SPEAKER_00: All right, but anyway, those are the things we're investigating, and it's top of mind right now because we have a I've we've I've worked with a a handful, you know, tons of people of athletes like this with medial elbow issues and it and manifesting into anterior shoulder pain, which is a really common concurrent thing that happens.
• 17:40
  SPEAKER_00: But uh it's just top of mind because we're working on that right now with uh with a young kid that as a thrower.
• 17:46
  SPEAKER_00: But anyway, there is hope.
• 17:47
  SPEAKER_00: All right, and there they're with the other message I want to convey is if it's a musculoskeletal issue, all right, and uh let's say an MRI found that there's no tearing, like not significant tearing in the in the uh UCL, or like an ultrasound guided image is finding that the UCL is intact, but you're having pain there.
• 18:08
  SPEAKER_00: Well, we need to find out all those components we mentioned before.
• 18:11
  SPEAKER_00: Why is the elbow getting overwhelmed in the first place?
• 18:14
  SPEAKER_00: And then what do we do to intervene?
• 18:15
  SPEAKER_00: All right, the manual therapy and the extra corrective exercises to fix those issues that we talked about.
• 18:20
  SPEAKER_00: And if that's the case, that's what we do.
• 18:23
  SPEAKER_00: That's the person that you need to go see.
• 18:25
  SPEAKER_00: Is somebody like that that has that lens and the um repertoire of exercise, corrective exercise selection and also manual therapy to set it up for success.
• 18:36
  SPEAKER_00: That's the best recipe, in my opinion, is manual therapy interventions to set things up for success for mobility and activation, and then corrective exercises to solidify those changes and fix the moving pattern.
• 18:48
  SPEAKER_00: That's the solution over many, many weeks and months of working into that, and then progressing back into throwing again and consulting with the pitching coach, because we're not pitching coaches or throwing coaches, but we do know biomechanics and pain and where the pain's coming from and what biomechanical compensations are causing the issue.
• 19:05
  SPEAKER_00: That's what we do.
• 19:06
  SPEAKER_00: Um, and then progressing back in and fixing consulting with the pitching coach and throwing coaches um for fixing the mechanics, all right.
• 19:14
  SPEAKER_00: And then cues and tips and uh working points to fix to fix the throw mechanics.
• 19:21
  SPEAKER_00: So that's that's the medial elbow.
• 19:22
  SPEAKER_00: All right, that's throwers pain, medial elbow throwers' pain, and the difference between golfer's elbow.
• 19:28
  SPEAKER_00: So if you have any questions or if you know a thrower or anybody battling medial elbow issues or shoulder issues, give us a call.
• 19:34
  SPEAKER_00: We can at least talk in the phone and see what you have going on and how we might be able to help you.
• 19:38
  SPEAKER_00: And we're always open to suggestions and ideas for the podcast, too, you know, guests and stuff.
• 19:41
  SPEAKER_00: So don't hesitate to reach out with questions, comments, concerns, or conflicting opinions.
• 19:47
  SPEAKER_00: And we're always we're always here to help you.
• 19:49
  SPEAKER_00: We'll catch you all next time.