Elbow Pain in the Boxer – Dealing with Hyperextension Injuries

 

Elbow pain is fairly common in sports that are demanding of the upper extremity.  For example, many of the elbow pain cases we see in the sporting environment are in golfers, throwers and strikers (think boxing, racket sports, volleyball).  

I am currently working with a National level boxer here in Quebec, Sabrina Aubin.

She has been struggling with an elbow injury for quite some time, which has resulted in pain, disuse atrophy of the upper extremity, decrease capacity for training and boxing and as you can imagine, has a potential hindering impact on her career.

Plus, as she never fails to mention, she can’t wait to punch someone in the face!  (I wouldn’t want to get punched in the face by her but I can make sure she can punch someone else…) 

In boxing, elbow pain complaints are more often due to posterolateral elbow impingement, which is caused by repetitive hyperextension trauma during missed punches.  

However,

 

the combined movement of hyperextension and pronation of the arm is thought to be the specific trauma mechanism

 

boxing photo

 

This means that the repetitive movement in itself could contribute to elbow pain (1).

While injuries do happen in sport, and missing the target is a real possibility in boxing, there are factors that can be addressed to both treat and prevent elbow pain and elbow hyperextension.  

They key to an efficient rehab is intervening quickly on pain and load tolerance and improving the athlete’s ability to dynamically stabilize the elbow.

Of the many elements that go into the elbow pain rehab structure that I have established for Sabrina, this article will focus on:

  • Managing pain
  • Improving upper limb tolerance
  • Restoring proprioception and dynamic joint stabilization
  • Improving reactive neuromuscular control
  • (And finally, punching someone in the face)

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MANAGING ELBOW PAIN

Isometrics

In my experience, if the elbow has become sensitive, it will be particularly irritable with movement and/or activity.

 

Managing pain is always a priority, because an athlete will always move based on pain, either by compensating or over-protecting the area

 

Isometrics work well in the early stages to both manage elbow pain and prevent disuse atrophy.  For one, isometrics don’t involve any movement and are usually quite tolerable and manageable for the athlete.  

Isometrics also provide an analgesic effect.  Exercise-induced hypoalgesia is a well-documented phenomenon.  

In their meta-analysis, Naugle, Fillingim, and Riley (2012) found that isometric exercise reduced pain perception across all pain stimuli (experimentally induced noxious stimuli) (2).

Many other studies have also shown that submaximal isometric contractions engage a centralized pain inhibitory response.

Isometric holds in various angles of elbow flexion in pronated, supinated and neutral positions work quite well and have the added advantage of loading the musculature of the forearm, a key component for elbow pain rehabilitation.

The optimal dose of exercise that is needed to produce hypoalgesia is not well-documented and since there is no consensus on optimal dosage, I advocate individualization based on the limiting factor:

-If elbow pain limits the intensity of contraction that is possible, opt for low-intensity, long-duration isometrics, for example, 3 sets of 45 seconds.

-If elbow pain limits the duration the contraction can be held, opt for multiple sets of lower-duration isometrics, for example 2 sets of 5 x 10 second holds.

If you want to harness more of the power of isometrics, see this article: The Power of Isometric Exercise in Training and Rehab

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Tendon glide exercises

I have also found tendon glide exercises to be particularly effective for both managing elbow pain and restoring load into the forearm muscles:

I typically program these for 2 sets of 8 repetitions.

 

IMPROVING UPPER LIMB TOLERANCE

The elbow is located between the hand and the shoulder.  PhD level anatomy right there, am I right?  

What I am trying to say is that the intricate function of the upper extremity starts at the hand and involves the wrist and elbow all the way up to the shoulder

The various muscles that cross the wrist, elbow and shoulder joints work together to distribute load.  If the elbow is injured, painful, or otherwise unable to tolerate load, this force distribution is perturbed.  This means potential trouble down the line for the hand, wrist or shoulder.  

It also means we need to restore this limb load tolerance and distribution as a whole. This concept is explained in marvelous detail by the guys at ikneurology. Their upper extremity limb load tolerance exercises work wonders to both restore load tolerance and show the nervous system that the extremity can handle load.

I typically program these for time, similar to the parameters for the isometric exercises mentioned above.

WATCH THE MAIN VIDEO OF THE ARTICLE TO SEE HOW TO DO THESE EXERCISES

 

PROPRIOCEPTION AND DYNAMIC STABILITY

When restoring proprioception, open kinetic chain exercises are useful, as they target awareness and control. Butler and Major (2003) proposed revised definitions for kinetic chains, introducing controlled closed and controlled open kinetic chains (3).

They state that: “in a controlled open kinetic chain, it is implicit that all articulations are under active control at all times”.

In order for an open kinetic chain to be effectively maintained, the athlete must have the neuromuscular control to resist the moments acting about all joints.  Working on this capacity is also particularly important is you are dealing with a hypermobile athlete.

The following exercise creates an extension moment of the entire upper extremity, helping Sabrina focus on maintain alignment and preventing hyperextension at the elbow.  It is also an additional way to work on improving limb load tolerance:

Depending on tolerance, you can program this for longer duration isometrics, or repeated bouts of short duration isometrics.

You can also use variations of open chain plyometrics to work on dynamic stabilization.  This focuses on preparatory agonist-antagonist coactivation to anticipate and react to joint loads. 

Efficiency of coactivation allows for better distribution of joint forces to reduce both the load imparted to the static structures and excessive movement of the joint.  

Here is an example:

 

REACTIVE NEUROMUSCULAR CONTROL

The end goal of rehabilitation is to allow the athlete to return to function in their specific sport environment and tasks.  A rehab progression should allow the athlete to progress towards the reacquisition of the specific movements, loads, postures or skills related to their sport.  (Or to punch someone in the face.)  

Synergy and synchrony of muscle firing patterns during sudden changes in joint position is required for proper joint stabilization (4):

In the case of boxing, this very simply means the appropriate reactive neuromuscular control required to throw a punch without excessive elbow extension.

 

MANY ANGLES TO COVER

The soft tissue surrounding the elbow joint play an important role in providing dynamic support of the elbow, but this is a finely tuned strategy.  

As discussed earlier in this article, elbow pain in boxer’s can be the result of repetitive movement exceeding the normal physiologic range of motion of the joint.  

Managing pain and improving load tolerance, proprioception and neuromuscular control are all important in protecting the joint by restoring the appropriate dynamic balance of the surrounding muscles.

If your athlete wants to punch someone in the face and have it hurt their opponent, you want to be sure it is the opponent who will be in pain, not your athlete.  Making sure you include all of these crucial components in your rehab plan will get them there!

A very special thanks to Sabrina for her trust and hard work.

 

References

  1. Valkering, Kars & van der hoeven, Henk & Pijnenburg, Bas. (2008). Posterolateral Elbow Impingement in Professional Boxers. The American journal of sports medicine. 36. 328-32. 10.1177/0363546507308937
  2. Naugle, K., Fillingim, R., & Riley, J. (2012). A Meta-Analytic Review of the Hypoalgesic Effects of Exercise. The Journal Of Pain, 13(12), 1139-1150. doi: 10.1016/j.jpain.2012.09.006
  3. Butler PB, Major RE. The Missing Link?: Therapy issues of open and closed chains. Physiotherapy. 2003 Aug 31;89(8):465-70.
  4. https://www.rehabeducation.com/wp-content/uploads/2014/09/Impaired-Neuromuscular-Control-RNT.pdf

 


 


Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U

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