I can’t tell you what’s wrong with you by looking at a picture of you. From the get-go, I should say that sending me a pic of yourself shirtless on Instagram or Messenger, without a hello, and when we have never even had a conversation is, well, weird.
I receive so many pictures with questions like “My right shoulder is lower, what do you think is wrong and how do I fix it?” or “My right lat won’t contract, you can tell it’s smaller than the left one in the pic, what could be wrong?”.
I launched the Pick my Brain segment to answer questions, but unfortunately, these are not the kind of questions I can answer. Any question that inherently requires a full assessment is not something I can answer with one answer based on one pic or even one conversation, actually. Besides, if something is really bugging you and you want to fix it, you should be looking to get a full assessment, not a quick fix. I can’t tell you what’s wrong by looking at a picture and neither can anyone else, for that matter. Nor can you fix yourself with exercises you find on Instagram. These days, we are in an era of “quick fixes”, as if that really exists. If it takes a 12-week periodization to get you jacked, why would you think 1 single exercise can fix an injury? Or that I could sum up what you can do to fix yourself in a direct message conversation? As a trainer, stop looking for the best exercises to fix X, Y and Z. It’s much more about the process, not so much the exercise.
All that said, if you do have a question (one I can likely answer), please send it in to me and we can include it in one of our Pick my Brain segments.
MANAGING PAIN
This week’s second question is from a Crossfit athlete complaining of inner elbow pain during rope climb or heavy dumbbell snatches asking for my thoughts on what the issue might be or what might help. Although this is also something that requires an extensive assessment, there are portions of the question that I can shed some light on, so I thought it would be a good question to include with the “fix me based on one picture” topic.
I always like to take time out to remind everyone how important it is not to suggest any diagnoses, online or otherwise, if that isn’t within the scope of your practice. That does not mean that having an understanding of common pathologies and their signs and symptoms isn’t important. Knowing what movements trigger pain and what that might mean for a particular muscle or structure so that you can make appropriate and necessary modifications to your intervention is actually very important.
The medial aspect of the elbow, specifically the medial epicondyle, gives attachment to the common flexor tendon. The common flexor tendon is the convergence of 5 muscles: pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris.
Pain on the medial epicondyle is often diagnosed as medial epicondylitis. But beyond looking for a diagnosis, let’s focus on the fact that pain in the location of the common flexor tendon that is exacerbated by heavy gripping and wrist flexion exercises such as a heavy dumbbell snatch or rope climb probably indicates that we have exceeded the tendon’s capacity to recover from this load.
The fact alone that these types of movements are currently triggering pain means that we should consider temporarily easing off them. That would be my first and foremost recommendation.
Even with so little information, and even on the off chance that the common flexor tendon was not the problem, managing pain should always be the first part of a rehab strategy because pain will change the way individuals move. This is the body’s protective mechanism and is very effective but unfortunately, this can create compensation that will last beyond the pain itself. Allowing an individual to train with pain or pain-triggering movements, or even movements that have the potential to trigger pain can lead to compensation and potentially, problems somewhere else along the kinetic chain down the road.
TENDON-GLIDING EXERCISES
Although they are typically used for conditions such as carpal tunnel syndrome and various conditions involving the fingers, I have found tendon-gliding exercises to be useful for issues involving the elbow. I have also found them to have an analgesic effect.
Tendon-gliding exercises allow the flexor tendons to glide to their maximum potential. They can help decrease adhesions and they gently load the flexor tendons. I prefer these to static stretching of the flexor muscles. If I did want to release the flexors prior to performing the tendon gliding exercises, I would prioritize soft tissue work over stretching as well.
There is a general over-emphasis on stretching with tendon issues. But tendons don’t need stretch, they need stiffness. On the other hand, addressing the associated muscle belly using soft tissue work can help with fascial gliding and prevents compression of the bony cam of the joint on an already irritated tendon which a stretch would generate. Just to be clear, I’m not saying don’t stretch ever. I’m saying stretching an already irritable tendon may not be appropriate, at least in the early stages.
Tendon-gliding exercises are performed by essentially making different types of “fists”. I like to use two different gliding exercises: the hook fist and the straight fist exercise. What’s most important is keeping the wrist neutral. In later stages and/or with lateral elbow pain, wrist flexion can be progressively introduced.
Watch the main video of the article to see how these are performed.
LOAD MANAGEMENT
Stress on normal tissue leads to adaptation. This is the entire premise of training. However, if you overload a tissue either by loading it too much, too quickly, or by not allowing it sufficient time to recover, you get failed healing. Then you need to be much more precise about HOW MUCH you load it. Tissues do not benefit from being under loaded, so selecting exercises that still allow you to load the tendon in a non-painful position and without creating compression is important.
WRIST FLEXION
In the early phase of rehab, the neutral wrist will be your best friend. In some cases, this starts with a standard form check. Is the client flexing the wrists when they are performing their pulling exercises? I still see this a lot in the gym with exercises like TRW rows, lat pulldowns and pull ups.
The pronator teres also has an attachment on the medial epicondyle. I have found that when there is pain in that region, forceful pronation is also often irritable. Temporarily replacing pronated grip pulling variations and prioritizing neutral or supinated grips may be helpful.
WRIST EXTENSION
Wrist flexion is not the only enemy. Wrist extension places the flexors on stretch and can be quite irritable, especially if loaded. Push-ups likely won’t be very tolerable. Consider using a variation on dumbbells with the wrists in a neutral position, if the individual has that capacity. They could even do it in an inclined position to lessen the load on the wrists. Otherwise, replace push-ups with a pressing exercise that is more neutral-wrist friendly.
LOADED CARRIES
I’m one of those people who can’t find much wrong with carries. All kinds of carries, all kinds of grips, all kinds of objects, the more awkward the better. Carrying an awkward object is probably the best core exercise out there. Anyway, there I go… Getting back to elbow pain. The grip work of performing a simple carry (farmer grip) is great for loading the flexor tendons in a tolerable position and the load is easy to monitor. Because the movement of the weight with a carry has a “dynamic” effect on grip, you could even start with just a hold and progress to a carry.
INVEST IN FIXING YOURSELF
No one can fix someone based on one picture, or even one question. This article is just an example of how much goes into answering one simple question. Actually, the best answer to most questions is probably “it depends”. A lot goes into identifying a problem, figuring out what contributes to that problem and building an actual plan to manage this problem. Sharing thoughts and experiences on social media is meant to help you realize that as a client or as a professional. It is meant to trigger you as a client to invest in the help of a qualified professional instead of looking for a quick answer or a single magic exercise to fix you. It is meant for you as a trainer or therapist to appreciate that it is less about protocols and more about problem-solving. As my good friend Christian Thibaudeau says, a good coach is a problem-solver.
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Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U
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